Prof. Ernest Schilders
Leeds Metropolitan University
Bradford Teaching Hospitals

Start
Which procedure?
Operative
Findings
Pain
Orginal pain
Procedure specific
Rehab related
Hip arthroscopy
Rehab
Return to sport?
Type of sport
Fitness
Type of procedure
Progress of the rehab
Patient orientated
Use assessment criteria

 What is the exact procedure and operative findings?
Faster rehab program for simple and longer for complex procedures.
 How long was the patient injured before his surgery?
Conditioning is a very important element of the rehab.

80%
70%
60%
50%
40%
30%
20%
10%
0%
FAI Instability Ligamentum
Teres Tear

80%
70%
60%
50%
40%
30%
20%
10%
0%
Labral tear cartilage lesion adhesions ligamentum teres tear

generalized cartilage degeneration wave sign
Partial thickness full thickness
0% 5% 10% 15% 20% 25% 30%

simple
Intermediate complex
Very complex
Diagnostic,
Removal loose body
Labral debridement
Ligamentum Teres debridement
CAM decompression
Iliotibial band release
Iliopsoas release
Acetabular rim trimming + labral repair + CAM decompression
Microfracture (prolonged crutches)
Acetabular rim trimming+ labral repair+ CAM decompression + capsular plication

Microfracture ligamentum teres debridement resection cartilage flaps capsular plication acetabular rimtrimming
CAM decompression labral repair
0% 10% 20% 30% 40% 50% 60%

 FAI surgery (1-4 week crutches PWB)
 Microfracture (prolonged use of crutches 6-8 weeks)
 Capsular Plication (use of night splints in internal rotation for 4 weeks)

 Pain and a negative hip arthroscopy
 Presence of extensive grade 4 cartilage lesions.
 Generalised hyperlaxity in patients with instability symptoms.
 Centre edge angle below 20 degrees.
 Low preop outcome score.

20y old professional football player
• CE angle= 20
• vertical sloping weightbearing surface.
• Perthes disease
• Generalized hyperlaxity

 Muscle relaxant at induction (Atracurium 0,6mg/kg)
 Remifentanyl infusion during surgery for blood pressure control, muscle relaxation and analgesia.
 Multimodal analgesia at the end of the surgery. NSAID/ paracetamal and morphine.
 Postoperative pain relief consists of codeine, paracetamol and NSAID
 Antibiotics administration at induction.

Process whereby patient/player progresses through rehabilitation, achieving goals within specific timescales.
Easy to follow.
Based on evidence and agreed with consultant involved.

 Use realistic timescales (Always err on the side of caution).
 Use common sense, as injured patients/players will progress at different rates.

Frank Gilroy
Post surgical general rehabilitation ladder
Increased shearing activities, agility, sports specific rehab
Advanced strengthening and proprioception
Regain full ROM
Increased strengthening and proprioception
Surgery
Pre-op preparation
Regain ROM
Early strengthening
Timescales depend on consultant involved

8-12 week ladder Playing again!
Phase 4
Short sprints and shuttle runs, increasing core stability work. Gradual return to sports specific training
Phase 3
Straight line running, strengthening exercises, increased pool work and full stretches
Phase 2
Jogging 20-30 minutes, light stretching and pool exercises
Phase 1
Gentle walking and light stretching
Surgery
Pre-op preparation
Timescales depend on consultant involved

Week 1
 Ankle pumps

Week 1
 Ankle pumps,
 Isometrics – Gluteal, Quads, Trans Abs, Hip abduction

 These are static exercises. When you do the exercise you should feel the muscles tighten without movement of the joints.
Try to do twenty repetitions of each exercise, 2 times a day.

 Gluteal sets: tighten your buttock muscles – hold for 5 seconds.
 Quads sets: tighten the front thigh muscles – hold for 5 seconds.
 Transversus Abdominus
:
Draw belly button in towards spine without moving pelvis/spine – hold while taking 5 breaths.
 Hip abduction
: Lying on your back with hip and knees bent, place a belt around your thighs near your knees and push out against the belt – hold 5 seconds

Week 1
 Ankle pumps,
 Isometrics – Gluteal, Quads, Trans Abs, Hip abduction
 Stationary bike – start 20 mins x 2 daily

 Stationary Biking with high seat and minimal
resistance.
 As soon as you are comfortable enough to get onto a bike, cycle for 20 minutes 2 times a day.
 Increase the time by 5 minutes after 3-4 days until you have reached a maximum of 45 minutes twice a day.
 No resistance should be added until week 5-6.

Week 1
 Ankle pumps,
 Isometrics – Gluteal, Quads, Trans Abs, Hip abduction
 Stationary bike – start 20 mins x 2 daily
 Passive stretching, Piriformis stretch (side lying),
Quads stretch (prone), Adductor stretch (sitting)

 Lying on your good side
(bottom leg straight and pelvis stacked) bend your involved hip to between
50° to 70° flexion and hook top foot behind uninvolved knee. Steadying the pelvis, lower the involved knee towards bed. Stretch should be felt in buttock, avoiding a pinch in groin.
Piriformis stretch

 Do 5 repetitions, hold for
20 seconds, and twice a day.
 Lie on your stomach with your hips flat on the bed.
Ask a partner bring ankle toward buttock, feeling stretch in the front of the thigh.
 If it is too painful to lie on your front, you can do this stretch lying on your good side.

 Do 5 repetitions, hold for
20 seconds, and twice a day.
 Sit in a chair with the feet on the floor. Carefully move the knee of the affected leg out to the side so the hip is opening out
(abducting). Do the stretch as comfort allows and feel the stretch on the inside of the thigh.

Week 1
 Ankle pumps,
 Isometrics – Gluteal, Quads, Trans Abs, Hip abduction
 Stationary bike – start 20 mins x 2 daily
 Passive stretching, Piriformis stretch (side lying), Quads stretch (prone), Adductor stretch (sitting)
 Price

Week 2
 Week 1 exercises (including)
 Quadruped rocking

 3 sets, 20 repetitions, once a day.
 On your hands and knees shift your body weight forward on your arms, and then back onto your legs.
Also shift your weight side to side and in diagonal directions.

Week 2
 Week 1 exercises (including)
 Quadruped rocking
 Standing Hip IR

 3 sets, 20 repetitions, once a day.
 Place knee of the operated leg on a chair. Rotate the hip by moving your foot outward from the body. Progress the exercise by using a resisted band when tolerated.

Start position Finishing position

Week 2
 Week 1 exercises (including)
 Quadruped rocking
 Standing Hip IR
 Heel slides with/without strap
 Cons r/v

Weeks 3-4
 Pain relief – Price, electrotherapy or mobilisation
 Gait re-education
 ROM exercises (Cont week 1 & 2 exercises)
 Stretching (piriformis and quads) include Faber, calf, hamstring and ITB
 Gym work (if appropriate) Bike – no resistance but increase time
(aim to build for 45 mins x 2 daily), Leg press – low weights and repetitions, Cross trainer – min resistance monitor time, Swiss ball
 Core stability
 Hydrotherapy

lying on your back bring involved leg into a figure four position with the ankle resting above the opposite knee. Gently lower the bent knee towards the floor. You may need to start with ankle resting on the shin or inside of the leg. It is normal to feel some hip discomfort underneath the thigh. DO
NOT PUSH ON THE KNEE.

Weeks 3-4
 Pain relief – Price, electrotherapy or mobilisation
 Gait re-education
 ROM exercises (Cont week 1 & 2 exercises)
 Stretching (piriformis and quads) include Faber, calf, hamstring and ITB
 Gym work (if appropriate) Bike – no resistance but increase time
(aim to build for 45 mins x 2 daily), Leg press – low weights and repetitions, Cross trainer – min resistance monitor time, Swiss ball
 Core stability
 Hydrotherapy

Weeks 5-6
 Cont weeks 1-2 and 3-4
(include the follwing)
 Gym work within capabilities
( inc resistance on bike alter time)
 Balance work – wobble board, trampette
 Core stability – progress as able
 HEP – lunges, lateral side steps, knee bends, fartlek
(jog/walk)

 Week 1-2 exercises can be stopped
 Cont with weeks 3-4 and 5-6
 Increase hydrotherapy exercises (squats, step ups/downs, ¼ - ½ lunges.
 Running – progress from straight line to multi-directional
 Sports specific

 How do we know that our rehab is progressing steadily, what is normal and what is abnormal?
 What are the standards we can realistically aim for?
(measurements of outcomes)
 Can we separate the built up of fitness from a hip arthroscopy specific rehab program?

 Pain
 Functional scores
Modified Harris Hip Score
Hip outcome osteoarthritis score (HOOS)
SF 36
 Subjective assessment?
 Objective Static information
Range of motion
Strength test
Log roll test
 Objective dynamic evaluation
SPORTS TEST

 Procedure related
Adhesions, microfracture, labral repair, decompression CAM or pincer. INFECTION
 Traction related adductor pain
Pectineus
Sciatic pain
Ankle pain
 Rehab related
Iliotibial band and trochanteric bursitis
Psoas
Hip flexors
Synovitis
 Sacro iliac joint pain.

 Pain:
Reintroduce analgesia, NSAID rarely steroid injection.
Limited rest
Concentrate on Deep Rotators of the hip.
 Stiffness:
ROM stuck (very rarely) ; check X rays or CT scan to investigate for residual impingement

 More complex arthroscopic procedures.
 Pre-operative sensations of stiffness that limits function.
Possible risk factors
Longer time on crutches
Grade 4 articular cartilage lesions treated with microfracture.

 Compression of the trochanteric bursa due to iliotibial band tightness.
*Weakness of the hip abductors causing increased hip adduction.
*Swelling bursa due to fluid extravasation.
*swelling and insufficiency muscles due to portal trauma.
 Osteopathic technique to reduce the tightness, myofascial release. “ counterstrain a positional release technique”.

 Weakness of the hip abductors and imbalance between adductor/abductor strength.
 Reduced hip mobility compared to controlateral side an issue to address early in the rehab, before athletes have increased their activities to significantly

 Pain
 Functional scores
Modified Harris Hip Score
Hip outcome osteoarthritis score (HOOS)
SF 36
 Subjective assessment?
 Objective Static information
Range of motion
Strength test
Log roll test
 Objective dynamic evaluation
SPORTS TEST

 Preoperatively
 2 months postop
39-96
58-100
 6 months postop 74-100
 Minimum of 12 months postop.
70-100

 Overall the average pre-op MHHS was
62.1 (95% CI 57.8-66.4) and the average post-op MHHS , after minimum 1 year, had statistically significantly increased to 94.8 (95% CI
92.8-96.9) (p<0.001).
 Average return to sport was 2.4 months .

 Pain
 Functional scores
Modified Harris Hip Score
Hip outcome osteoarthritis score (HOOS)
SF 36
 Subjective assessment?
 Objective Static information
Range of motion
Strength test
Log roll test
 Objective dynamic evaluation
SPORTS TEST

Test Components
1.Single knee squat (single knee bend)
2 Lateral agility test
3. Diagonal agility test
4. Forward single leg lunges
Maximum score
6 points
5 points
5 points
4 points
Total 20 points

 Passed
> or = 17 points
Scoring criteria subsets
Time 20-30 seconds
Endurance
Form
Pain
Total 1 point
 Failed
< 17 points

 Difficult to predict.
 Should be athlete orientated rather the rehab orientated.
 Need for objective measurements before allowing athletes to go back to sports.

 History of injuries and low level of off-season sport specific training.
 Consider the time an athlete has been out with an injury, before having surgery.

 Persistent Pain
 Prolonged rehabilitation time.
 Low performance
 Re-Injury( new labral tear, articular cartilage lesion)
 New Injuries.
Emery et al. Med SciSports Exerc, 2001.

 Lack of endurance in sports specific tasks.
 Pain in sports specific positions.
Progressive adaptations can be feasible. Dressage: start with small horses before wide horse, stirrups higher, to sit in a flexed more abducted position.

 Endurance muscles fibers are the first to be lost after hip surgery and take longer to recover.
Suaetta et al. J ApplPhysiol, 2008.
Deschenes et al. Am J Physiol, 2002.
Ferrettiet al. J ApplPhysiol, 2001

 If possible see patient/player pre-operatively to prepare joint involved, and explain process and timescales involved.
 Always work closely with the surgeon involved.
 Whenever possible follow evidence based guidelines.

rockclimbing netbal martial arts rowing dance cycling hockey tennis basketball running horse riding golf rugby soccer
0 2 4 6 8 10 12 14

 Soccer
 Rugby
 Basket ball
 Hockey
 Dance
 Martial arts
 Tennis
2-4 month
2-3 month
5 month
3-4 month
3 month
3 month
2 month sports involving twisting and turning

 Golf
 Cycling
 Running
 Rowing
 Rockclimbing
2-3month
6week-2 month
2 month
2 month
3 month
Sports not involving twisting and turning

Start
Which procedure?
Operative
Findings
Pain
Orginal pain
Procedure specific
Rehab related
Hip arthroscopy
Rehab
Return to sport?
Type of sport
Fitness
Type of procedure
Progress of the rehab
Patient orientated
Use assessment criteria